Hontiveros Seeks Audit Of Philhealth’S Case-Based Payment System

Senator Risa Hontiveros on Wednesday proposed several steps to protect the Philippine Health Insurance Corporation (PhilHealth) from fraud and other related scams. Chief among them is a proposal to audit PhilHealth’s current case-based payment system which reimburses health care providers with a pre-determined fixed rate for each treated case or disease.

Coinciding with a Senate Blue Ribbon Committee hearing on alleged corruption inside the health department, Hontiveros scrutinized the implementation of Philhealth’s “case based payment system” and asked PhilHealth to produce its most recent compliance figures, as well as current protocols in addressing gaps in implementation.

“The case based payment system has to be reviewed. Other options for paying providers should be explored and implemented,” Hontiveros said.

“Serious allegations of fraud and financial mismanagement erode public trust in our healthcare institutions and endanger the lives of people by denying them the medical treatment they need. We need to have more stringent procedures to protect the public health sector against bad and abusive practices. And if these procedures are already in place, they sorely need to be revisited and implemented. And those who have failed to implement these processes should also be held accountable,” Hontiveros added.

It was reported that there are cases of overpayment of cases of pneumonia, caesarian section, and the Z package, among others. This was also reportedly raised by the Commission on Audit (COA) during the years it was implemented. COA has suggested that PhilHealth revisit the implementing guidelines of this policy and to ensure that only valid
expenditures be reimbursed.

“SHIFT TO A STRATEGIC PAYMENT MECHANISM”
Hontiveros supported moves for Philhealth to shift to a more strategic provider payment mechanism such as the Diagnosis Related Group (DRG). She said that she included the DRG as one of her amendments to the Universal Health Care (UHC) Law.

“The DRG is a system used to classify various diagnoses for in-patients into groups and subgroups so that insurance can accurately pay the hospital bill. The main idea behind this mechanism is to ensure that reimbursements adequately reflect the fundamental role which a hospital’s case mix plays in determining its costs and the magnitude of resources that the hospital needs to treat its patients,” Hontiveros explained.

The Senator also asked PhilHealth to produce and explain the current levels of support it provides its staff who report anomalies and to regularly publish their current financial data on reimbursement claims for stronger transparency. Meanwhile, Hontiveros is set to file the Philhealth Insurance False Claims Bill to deter and minimize fraud in Philhealth and strengthen the corporation’s anti fraud detection systems.

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